Today’s New York Times features another tale from the land of variation.

Cardiologist Mark Midei inserted 30 cardiac stents in patients in a single day in 2008. The stent manufacturer (Abbott) purchased a $2159 barbeque dinner including a slow-smoked whole pig for the cardiologists’ home two days later.

The pig is a great headline, and a savory metaphor for the problem of overuse of high-margin procedures, some of which are invasive and have clear associated dangers. The hospital subsequently notified 585 patients that they might have received medically unnecessary stents. 585! This is mind-boggling.

This story, initially reported in the Baltimore Sun, is reminiscent of the Tenet hospital in Redding, California. That hospital built an empire providing cardiac surgery with very low complication rates – but it turned out that many of the cardiac surgery patients had normal coronary arteries.

See Shannon Brownlee's excellent 2007 book Overtreated for the details.

It’s especially interesting how this physician’s behavior was revealed. His cardiology group had agreed to be purchased by the local hospital, but the hospital turned around and made him a separate deal and decided not to purchase the entire group. At that point, his spurned group attacked him, and a former chief executive vowed to“spend the rest of my life trying to destroy him personally and professionally.” The hospital has paid $22 million to settle federal charges of kickbacks to Dr. Midei's former group.

Most variation in health care is not as extreme as the allegations at St Joseph’s in Baltimore. Most physicians who practice at the 90th percentile of resource use don’t realize that they are using more resources than their colleagues, and few believe that they are performing unnecessary care. We need better reporting on resource utilization and continuing effective peer review. It’s a pity when peers are only effective at reining in rampant overutilization when they no longer inure benefit from that utilization.